Ob-Gyn Coding Alert

"The key to hassle-free claims for endometriosis care is making sure that each stage of the patients treatment is well-documented, especially the diagnostic reasons supporting additional visits and surgery. Claims for office visits and surgeries that are submitted without sufficient diagnostic support will pend for review, be denied or result in a lengthy appeals process.

Coding Stage One The Complaint

Diagnosis and treatment of endometriosis is a multistage process that begins with the patients initial complaint and usually ends with laparoscopic or sometimes open surgery. A patient with endometriosis may report to her ob/gyns office with one or more symptoms, such as dysmenorrhea (625.3), chronic pelvic pain (625.9), dyspareunia (625.0) or an adnexal mass (789.3x). But many women with endometriosis are asymptomatic, and the physician finds a nodule or mass on examination.

If the patients symptoms are minor or are not causing the patient a lot of pain, such as a minor backache at the time of menstruation, the physician may try the patient on an oral contraceptive, or change the dosage of an existing prescription to see if symptoms are relieved.

The ob/gyn will discuss the patients symptoms and perform either a comprehensive or problem-focused examination that will likely include a diagnostic Pap smear (88141-88167) and other tests to rule out other diseases or disorders. Under those circumstances, the visit for the initial complaint would be coded with an E/M code (99202-99205 or 99212-99215), based on the level of examination and/or history and medical decision-making (MDM).

The Pap smear can be reported separately from the E/M service, as can any blood tests or ultrasound examination (if an ovarian mass is noted on examination) the physician orders. At this point, even if the physician suspects endometriosis, he or she cannot use the ICD-9 codes for endometriosis until it has been diagnosed. Instead, he or she can only code for the symptoms present, not the suspicion of disease. Assuming the physician does not yet have a strong suspicion of endometriosis, he or she may choose to treat the problem less aggressively and monitor the patients condit-ion for a few more weeks or months.

Coding Stage Two If the Problem Persists

If the change in oral contraceptive or other steps taken do not relieve any of the patients symptoms, or she presents with other, more serious symptoms, such as (but not limited to) pelvic pain (625.9) or painful intercourse (625.0), the ob/gyn must take further action. This second E/M visit is coded 99212-99215 (office or other outpatient visit for the E/M of an established patient ...), depending on how much worse the established problem is getting and the degree of MDM and examination provided. The ICD-9 codes reported are for the discernible symptoms or the patients complaint, and not for endometriosis.

Coding Stage Three Laparoscopy or Laparotomy

The surgeon will decide which approach is best for the patient, a laparotomy approach (49200, excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas or 49201 ... extensive) or a laparoscopy approach (58662, laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method). If the endometriomas are removed at the time of the diagnostic laparoscopy, the laparoscopy is included with the surgical procedure and cannot be coded separately. If the diagnostic laparoscopy turns up no sign of endometriosis or the patient elects to undergo medical treatment for the condition after the surgical diagnosis is made, the diagnostic laparoscopy would be coded as 49320 (laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

If the laparoscopy does reveal endometriosis, the corresponding ICD-9 code(s) is applied. Selecting from the 617.x group of codes, the physician or coder indicates which areas are affected by the endometrial growth. If endometriosis is present in more than one area, each appropriate ICD-9 code would be used (e.g., 617.0, endometriosis of uterus, 617.1, endometriosis of ovary, etc.) until all affected areas have been matched with the proper diagnostic code. The coder has to know where specifically the endometriosis is to code the diagnosis to the highest specificity, says Katie McClure, RHIA, surgical coder for Southeastern Gynecologic Oncology, a six-physician practice in Atlanta. If the laparoscopy reveals no presence of endometriosis, the diagnostic laparoscopy code (49320) is linked to the code or codes for the patients original complaint, such as pelvic pain or dysmenorrhea.

Details in Operative Report Determine Codes

Determining whether endometriosis is present is not as difficult as documenting every place that it occurs in the body. This is especially important for extensive endometrial implants that require much more time to excise. If a surgery takes twice as long as a typical laparoscopy for treatment of endometriosis, the physician may be able to charge for that extra work by appending modifier -22 (unusual procedural services) on the lap code, says Melanie Witt, RN, CPC, MA, an ob/gyn coding expert and independent coding educator based in Fredericksburg, Va. But, the physician must document the extent of the endometrial implants and the extra time involved in order to support the -22. The -22 modifier should be used sparingly, when the work is truly unusual for the surgeon, and not just a slightly more advanced case of endometriosis.

An additional challenge in coding endometriosis surgeries occurs when the physician uses a different term for the destruction of the endometriotic tissue. Sometimes a physician will use lysis of adhesions for the procedure, and endometriosis for the diagnosis, McClure says. To report and bill the surgery correctly and link the correct diagnosis with the correct procedure, the coder has to read the operative report and determine whether the patient had adhesions that were lysed (49200), or if the patient had endometriosis that was fulgurated or excised (58662). I have found in coding these surgeries that I often have to request and review more information from the surgeon to determine the correct codes to bill, McClure says.

Infertility and Endometriosis

When a patient reports with pelvic pain, painful intercourse or other symptoms, coupled with an inability to conceive (628.9, infertility of unspecified origin), it may indicate endometriosis. But because HCFA and most commercial carriers do not recognize infertility as a disease, many will not pay for its treatment. Therefore, if a patient reports with several symptoms, including the inability to conceive, the physician should document every other complaint to support both the E/M visit and any other plan of care. You have to remember to code the symptoms unless you have confirmed a primary diagnosis of infertility, Witt says. Of course, that doesnt mean adding symptoms that are not present, but it does mean writing down every complaint that the patient has during that visit.

Additionally, when and if the patient is treated surgically for endometriosis, the ICD-9 codes accompanying the claim for the surgery should be for endometriosis and not for infertility. It may seem like a question of semantics, but it will make the difference in whether a claim is paid."